Pediatric Stroke: Diagnosis and Management in the Emergency Department - Stroke EXTRA Supplement

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Pediatric National Institutes of Health Stroke Scale (PedNIHSS)

• Introduction
• Points & Pearls
• Why and When to Use, Instructions and Next Steps
• Calculator Review Author
• Critical Actions
• Advice
• Evidence Appraisal
• Calculator Creator
• References

Introduction

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Points & Pearls

• The presentation of stroke in younger children can be subtle and may include altered mental status, depressed level of consciousness, and apneas.
• Presenting the questions and tasks in the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) as a game may aid in motivating patients, especially younger children.
• The developmental age of the child in the premorbid state must be considered. Consultation with the patient’s primary care clinician may be useful in estimating the patient’s developmental age; it may also be helpful to utilize a validated developmental screening tool that uses parental recall.
• Muscle strength in uncooperative patients may be assessed by careful observation of spontaneous movement or elicited movement, as compared to a developmentally and neurologically appropriate child of the same age as the patient.

Why and When to Use, Instructions and Next Steps

Calculator Review Authors

Derek Tam, MD, MPH

Critical Actions

Pediatric patients with sickle cell disease who present with acute ischemic stroke will likely benefit from emergent blood transfusion to reduce hyperviscosity. Early consultation with a pediatric hematologist, in addition to a pediatric neurologist, is recommended for these patients. 

Advice

Pediatric stroke is rare, and the true predictive value of the PedNIHSS is subject to change as the scale continues to be studied. Retrospective application of the PedNIHSS has been shown to be valid and reliable in 1 cross-sectional study (Beslow 2012). 

Evidence Appraisal

The PedNIHSS was developed by expert consensus of a panel of adult and pediatric stroke experts (Ichord 2011). The panel adapted the validated adult NIHSS to be appropriate for age-related variations in the comprehension of examination materials. The scoring strategy and ranges were not changed. The panel evaluated the interrater reliability of the PedNIHSS among 113 patients aged 2 to 18 years in a multicenter prospective cohort study. Overall, the interrater reliability was found to be quite high, ranging from 0.63 to 1.00 among the evaluating pediatric neurologists.

The PedNIHSS was externally validated by applying it to 75 children enrolled in a prospective study (Beslow 2012). Patients were scored both prospectively and retrospectively (based on the chart). Retrospectively applied scores correlated well with prospective scores (r² = 0.76). Interrater reliability was good overall (intraclass correlation coefficient of 0.95; 95% confidence interval, 0.94-0.97), with similar findings for individual test items.

Calculator Creator

Rebecca N. Ichord, MD

References

Original/Primary Reference

• Ichord RN, Bastian R, Abraham L, et al. Interrater reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a multicenter study. Stroke. 2011;42(3):613-617. 

Validation References

• Beslow LA, Kasner SE, Smith SE, et al. Concurrent validity and reliability of retrospective scoring of the Pediatric National Institutes of Health Stroke Scale. Stroke. 2012;43(2):341-345. 

Other References

• Mackay MT, Yock-Corrales A, Churilov L, et al. Differentiating childhood stroke from mimics in the emergency department. Stroke. 2016;47(10):2476-2481. 
• Lehman LL, Beslow LA, Steinlin M, et al. What will improve pediatric acute stroke care?. Stroke. 2019;50(2):249-256.